Submitting & Billing Claims
CenCal Health’s Claims department is committed to processing your claims as quickly and accurately as possible.
In general, CenCal Health follows the benefit and payment guidelines as published by the State of California’s Medi-Cal program. This information can be found on the Medi-Cal website www.medi-cal.ca.gov
Please submit a new W9 if you are changing your “Mail-To” and “Pay-To” addresses, and legal business name or ownership.
Timelines for All Lines of Business
Original (or initial) Medi-Cal claims must be received by CenCal Health within six months following the month in which services were rendered or the following payment reductions may apply:
- Claims received during the 7th, 8th or 9th month after the month of service will have final payment reduced by 25%.
- Claims received during the 10th, 11th or 12th month after the month of service will have final payment reduced by 50%.
- Claims received after the 12th month following the month of service will be denied.
There are exceptions to these billing limits. These can be found in the State of California’s Medi-Cal Billing Manual and at the following links:
- CMS-1500 Claim Timeliness Instructions
- UB-04 Timeliness Instructions
- LTC Form 25-1 Timeliness Instructions
For HF, HK, AIM and IHSS: claims must be submitted within 180 days from the date the service was rendered or claim will be denied, unless Provider can prove extenuating circumstances.
Other General Billing Information
Medi-Cal (SBHI & SLOHI)
Healthy Kids/Health Families/AIM
Prior Authorization for Services
ICD-9 & ICD-10 Diagnosis & Procedure Codes
Claim Adjudication Edits
CenCal Health employs industry standard edits for all lines of business when adjudicating a claim. Most are standard edits such as verifying the member’s eligibility, whether or not the services billed are plan benefits, the validity of the codes submitted, and if authorization requirements have been met. In addition, there are claim edits set forth by the Department of Health Services related to Medi-Cal benefit limitations that may affect editing.
For All lines of business CenCal Health also utilizes the procedure-to-procedure (PTP) NCCI edits that are published by CMS. The NCCI edit tables can be accessed at this link below, which will take you to the Main Page that contains the 2 sets of Hospital NCCI Edits and the 2 set of Physician NCCI edits.
To access the list of surgical codes with the number of follow-up days for each, click here: Surgical Follow Up Days – 2015
Child Health & Disability Prevention (CHDP)
Effective July 1, 2016, CenCal Health will begin administering the Child Health & Disability Prevention (CHDP) program covering members within Santa Barbara and San Luis Obispo counties. Providers must be certified under Medi-Cal, CHDP and Vaccines For Children (VFC) in order to provide these services. Below is the CHDP code crosswalk for purchased vaccines and the CHDP Code Conversion.
Avoiding claim denials and reductions in payment
- Claims submitted with dates of service prior to July 1, 2016, will be denied;
- Verify eligibility before rendering services and submitting your claim. Members who are not Medi-Cal eligible will be denied;
- Referral Authorization Forms (RAF’s) are required when the provider is not the members current PCP;
- Medi-Cal billing timelines apply. Claims received with dates of service beyond 6 months without a valid delay reason code will be reduced in payment;
- Do not resubmit a new claim when making a correction to a previously submitted or denied claim as this can result in a duplicate claim denial.
Please contact your Claims Service Representative for all corrections, inquires and/or questions on your CHDP claims.